CANCELLATION / ABANDONMENT

Transcription

1 CANCELLATION / ABANDONMENT CLAIM NO: Z Please complete this form in BLOCK CAPITALS and return it to Rightpath Claims as soon as possible with the following original documents ( where relevant ) : Proof of insurance Booking invoices ( for all providers, including travel agent ) Cancellation invoices ( for all providers, including travel agent ) Evidence of cause of cancellation ( for medical reasons, including those relating to third parties, please have the medical certificate at the back of this form completed) IMPORTANT: Documents will be kept for 6 months and then destroyed. Claimant details Title: First name: Surname: Date of birth: Daytime telephone number: address: Address: Postcode: Insurance Details Travel insurance policy number/ reference / collar number: Which company did you purchase your travel insurance from? Date insurance purchased: Other Claimant Details Name D.O.B. Relationship to Main Claimant Trip Details Country of destination: Resort/ town of destination: Date journey booked: Departure Date: Return Date: Trip duration: days Number of people insured: Name of Tour Operator ( if applicable ) : Name of Travel Agent ( if applicable ) :

2 Cancellation Details Please confirm the cause of cancellation: If the cancellation is resulting from a third party (i.e. non traveller) please confirm your relationship: When did it become clear you would need to cancel: When was the trip cancelled: : : If there was a delay in cancelling (from when it became clear you would need to) please confirm the reasons: Please use the following table to list the cancellation costs relating to the claim: Date Booked Provider Amount Paid Amount Refunded Amount claimed Curtailment Did you / cut / the trip short? What date did you return from : the trip? : : : : : The cost of the trip? : : : : : : : : : Totals: : : :

3 Recovery Information (do not leave any question blank as this will delay your claim) Part 1: Credit Card Details Do you have a Credit Card? How much of the trip was paid by Credit Card? NONE / PART / ALL Name of Credit Card Company: Type of credit card: e.g. gold, platinum etc.: IMPORTANT: DO NOT ENTER VISA / MASTERCARD AS THESE ARE THE PAYMENT PROCESSORS Part 2: Current Account Details A number of bank accounts now offer free, annual travel insurance as one of the benefits. Many people are unaware of this, so we ask all customers to confirm which company they hold their current account with: Name of Bank: Level and name of Account: e.g. Gold Premier, Royalties Gold etc.: Name of Account Holder if different from claimant (e.g. Parent): IMPORTANT: DO NOT ENTER CURRENT ACCOUNT WE NEED TO KNOW THE LEVEL OF ACCOUNT. Part 3: Dual Travel Insurance Do you have another travel insurance policy in place? Company Insurance was bought from: Name of policy (if known): Policy number (if known): Part 4: Third Party Liability In your opinion, was anyone else responsible for the injury/illness? Name: Contact details: Please explain the circumstances and why you feel they are responsible:

4 Payment Details If we can pay your claim, we will transfer payment directly to your bank account. Please confirm: Account No: Sort Code: - - Declaration I/ We declare that the above statements are accurate and correct to the best of my/ our knowledge. I/ We agree to provide the insurer with any further information which may reasonably be required. I/ We understand that by providing this form, the insurer does not accept liability. I/ We assign all rights of recovery/ salvage to the insurer and will do whatever is necessary to assign such rights. I/ We understand that the making of a fraudulent or exaggerated claim is a criminal offence and will leave us liable to prosecution. I/We give you permission to contact my doctor / specialist if you require further medical information regarding this trip cancellation. Signed: Print name: Date:

5 MEDICAL CERTIFICATE Z This form must be completed by the GP or attending specialist of the person whose medical condition gives rise to this claim. Any fee for completing this form is the responsibility of the patient/ claimant. To avoid delay and unnecessary correspondence, please complete this certificate in BLOCK CAPITALS, answering each question as fully as possible. The form must be returned to: Rightpath Claims, PO Box 6053, ROCHFORD, SS1 9TT, UK Telephone: +44 (0) Cancellation This form must be filled-in with relation to: (Please ensure this is completed before referral to the GP or attending specialist) Name of Patient: Date of Birth: Insurance Issue Date: Trip Booking Date: Medical Certificate: (To be completed by the GP or attending specialist) Q1. Medical Condition: Q2. Date symptoms first began: Q3. Date first consulted: Q4. Date first diagnosed: Q5. Date Cancellation could have first been reasonably anticipated: Q6. Details of any previous medical history relevant to the above condition, including the date of diagnosis: Q7. Has the patient been hospitalised in the 12 months prior to the Trip Booking / Insurance Issue Date? Q8. Was the patient on a waiting list, or under investigation on the Trip Booking / Insurance Issue Date? Q9. If you have answered YES to Q7 or Q8, please provide details: Q10. At the point of Trip Booking / Insurance Issue Date (see above), was the patient: On a waiting list: Taking any medication: Undergoing any tests: Aware of the condition: If YES, for what: If YES, for what: If YES, for what: Given a terminal diagnosis: If YES, the date the terminal prognosis given: Was the patient travelling contrary to medical advice? Q11. Was the cancellation medically necessary: Q12. If pregnancy: The date confirmed: The LMP: EDD: Q13. If stress/ anxiety/ depression/ mental / nervous disorder, is the patient under the care of a mental health specialist? Name of GP: Name & Practice (Group Stamp) Signature: Contact number:

6

7 CHECK LIST CANCELLATION / TRIP ABANDONMENT KEEP THIS PART OF THE FORM FOR YOUR RECORDS This part of the claims form may be kept by you. Use this CHECK LIST to help ensure you send us everything we need to conclude your claim on first review. Failure to provide us with all the relevant information and documentation will create delays. Whilst this form covers the main documents we may require further documents not listed. To make the process more efficient - please send us the information/documentation all together. ed attachments must be in JPEG or PDF format with a maximum size of 2MB. CLAIM FORM Have you answered all of the questions (including the recovery information)? Often questions that you may consider not applicable actually are - the reasons aren t always that obvious. Please ensure you enter your claim reference on the front of the form. BOOKING INVOICE / PROOF OF TRAVEL DATES These documents confirm the date the trip was booked and we can accept, booking invoices/ s. If you have not retained any of these documents whoever you booked through should be able to provide a duplicate copy of your booking invoice. PROOF OF INSURANCE We are independent claims handlers appointed by insurers to handle claims on their behalf. We do not always have direct access to your policy data. This is why we ask for a copy of your proof of insurance. If you have an annual multi-trip policy you can send us a copy. TRAVEL AGENT S BOOKING INVOICE If you booked through a travel agent please provide us with the original booking invoice issued by the travel agent as this will confirm any discounts that may have applied to the booking. CANCELLATON INVOICES Once you cancel a trip you must obtain a cancellation invoice from each and every supplier. This document must confirm the date cancelled and what refunds are due. If there was a delay in cancelling - please also provide the original booking terms and conditions as this will confirm how much the delay effected the cancellation costs (if at all). MEDICAL CERTIFICATE If your claim relates to the medical circumstances of you or another person, make sure the medical certificate is completed in full by the relevant GP or attending specialist and has been stamped. Please make sure all the questions have been completed by them and you are in agreement with what the doctor / specialist has put and resolved any queries with them before you send us the form. OTHER PROOF OF CIRCUMSTANCES If your claim is as a result of non-medical circumstances and we have not advised you already please contact us to check what documents will be sufficient to support your claim. COPIES TAKEN For safe-keeping we always recommend you take copies of your documents before sending them to us. Z Useful Information Date I sent the claims form to Rightpath: My Claim Number: If you are sending the claim form by post please allow up to 9 days for our response: 2 days for delivery, up to 7 days (5 working days) for the assessment and 2 days for a posted response. Rightpath Claims contact details: Address: Rightpath Claims, PO Box 6053, ROCHFORD, SS1 9TT Phone: / + 44 (0) enquiries@rpclaims.com